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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: Permit#: Inspection Date: w �� 22�.s 1/0 Lk Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (extends 2' from casing) Yes ANo ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes 0. No ❑ NA ❑ Chlorination port available and sealed properly Yes E2r No ❑ NA ❑ f SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes 6 No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ Cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes E] No [2f NA El Air a of at least 6" same as pipe diameter Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes 1NoE1 INA ❑ Well/Pump free from excessive ve etation IYes 2 1NoE1 INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes jNo ❑ Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: 0 Inspected B aron oderha Title: Registered Environmental Health Specialist Received B Date: EH-4200- 8/31/2015